Cases & Commentaries

Defensive Medicine: "Glowing" with Pain

Commentary By Manish K. Sethi, MD

The Case

A 31-year-old man presented to the emergency
department (ED) complaining of abdominal pain and vomiting. The
patient was well known to the ED staff (a "frequent flyer") as he
had presented multiple times in the previous 2 years with similar
complaints, always requesting intravenous hydromorphone (Dilaudid)
for the pain. In fact, he had been seen in the ED 2 days earlier by
the same physician who was on duty. At that time, the patient's
examination was benign, and a computed tomography (CT) scan of his
abdomen and pelvis was normal. He was discharged home with a
prescription for hydrocodone/acetaminophen (Vicodin).

On this visit, the patient stated that his
abdominal pain and vomiting had not significantly improved over the
prior 2 days. His vital signs were normal, and his abdominal exam
was unremarkable, with no tenderness, guarding, or masses. The ED
physician ordered laboratory tests and a CT scan of the abdomen and
pelvis, all of which were normal. Because of his persistent
symptoms, the patient was admitted to the hospital. An evaluation
by a gastroenterologist failed to reveal a clear cause for the
symptoms, and the patient was discharged to home after 2 days in
the hospital feeling somewhat better.

As part of a targeted review of intravenous
hydromorphone use in the ED, the Medical Director came across this
case. When she looked back over the prior 2 years, the patient had
been seen in the ED 12 times for abdominal complaints and had
received 12 CT scans of the abdomen and pelvis. All of them were
completely normal. When she reviewed the clinical details for each
of the 12 presentations to the ED, she felt strongly that most, if
not all, of the CT scans were not clinically indicated. When she
discussed the patient with the providers involved, many of the
physicians expressed that the CT scans (and many other tests) were
ordered out of "fear of getting sued"—as a safeguard against
possible malpractice liability. The Medical Director was frustrated
and wondered about the costs—to the health care system and to
patients—of practicing this "defensive medicine."

The Commentary

The intriguing case above describes a 31-year-old
man who was subjected to multiple abdominal CT scans during
emergency department (ED) visits. Although one could debate the
clinical indications for CT scanning in this scenario, the case
provides an appropriate backdrop to discuss defensive medicine more
broadly and outline the associated costs and consequences for
patient safety.

Defensive Medicine: An Issue
of Cost and Safety

In 2007, total national health
care spending was $2.3 trillion (representing 16% of our Gross
Domestic Product [GDP]) and rose by approximately twice the
Consumer Price Index.(1) Health
care spending in the United States is expected to continue to
increase at similar levels, potentially reaching 20% of GDP by
2016.(2) There are
many drivers for the rapidly increasing cost. One component of the
growing health care bill may be the expenses associated with
unnecessary medical tests, treatments, and procedures spurred by
physicians' fears of malpractice litigation. In a recent address to
Congress on health care reform, President Obama acknowledged that
these practices may be contributing to health care
inflation.(3)

Defensive medicine is
defined as medical practices that may exonerate physicians from
liability without significant benefit to patients.(4) Defensive
medicine can be divided into two distinct entities: positive and
negative.(5)
Positive defensive medicine, as in this case, occurs when
physicians provide excess diagnostic testing, treatment,
hospitalization, or consultation. Negative defensive
medicine
occurs when physicians curtail services to avoid
high-risk patients or procedures. A powerful example of negative
defensive medicine can be found in the field of neurosurgery where
many hospitals refuse to treat closed head injuries given the high
risk of medical liability involved.

How common is the practice of
defensive medicine? While prevalence varies in the literature, it
is clear that defensive medicine is commonplace.(6) For
example, a 1994 comprehensive study performed by the US
Congressional Office of Technology Assessment revealed that
approximately 8% of all diagnostic tests ordered by physicians were
purely defensive.(4)
Furthermore, a recent survey of Pennsylvania physicians in a range
of specialties indicated that more than 92% were actively
practicing defensive medicine.(7) In that
cohort who reported defensive practices, nearly all of them
practiced "positive" defensive medicine (92%) including ordering
additional tests, performing unnecessary diagnostic procedures, or
excessively referring patients for consultation. Interestingly, 42%
reported that they had taken steps to restrict their practice in
the previous 3 years because of liability concerns ("negative"
defensive medicine), and 49% stated that they were likely to do so
in the next 2 years
.

Research has also indicated that defensive
medicine is costly.(8) Many
attempts at quantifying or estimating the sum cost of defensive
medicine have been made. For example, a study of defensive medicine
published by the Massachusetts Medical Society in 2008 demonstrated
an annual cost to the state of Massachusetts of over $1.8 billion
annually.(8) While no
national study has been conducted, Reynolds and colleagues
published one of the first credible estimates in JAMA in
1987.(9) The group
estimated that total costs of the malpractice system for physician
services in 1984 were between $12.1 and $13.7 billion, accounting
for 15% of health care at that time.(9) In 1993, a
Lewin group report argued that the US health care system could save
nearly $36 billion over 5 years by taking steps to eliminate
defensive medicine.(10)

Defensive medicine is not only expensive; it is
unsafe for patients. For instance, patients subjected to
unnecessary radiological imaging are exposed to the risks of
radiation and possible anaphylactic reactions to contrast dye. The
patient in this case received 12 abdominal CT scans—equal to
or greater than the amount of radiation exposure received by those
in Hiroshima and Nagasaki. A recent study found that the use of CT
scans has increased threefold since 1993 and estimated that the 72
million CT scans performed in the United States in 2007 could lead
to approximately 30,000 future cancers.(11) Moreover,
other research revealed that radiation doses from typical CT scans
are higher and exposure more variable than commonly noted.(12) A typical
CT scan of the abdomen and pelvis can have enough radiation to
increase future cancer risk, and clinicians may not consider this
risk when deciding whether to use CT imaging.

Evidence suggests that rates of
some major surgical procedures, such as Caesarean sections, have
increased because of liability concerns.(13) In
complex patients, vaginal delivery may increase the risk of injury
to the mother or fetus; injuries in this setting often lead to
malpractice claims. Many obstetricians will choose to avoid
potential risk by performing a Caesarean delivery, even when it is
not indicated. For example, one study demonstrated that
obstetricians who practice in areas with high malpractice claim
frequency were 32% more likely to perform a Caesarian delivery than
similar doctors practicing in lower risk environments.(13)

In addition, given high rates of malpractice
claims, many specialists have closed their practices, stopped
performing high-risk procedures (e.g., spine or neck surgery), or
reduced their care of high-risk patients (patients who are
perceived by the physician to present challenging diseases and are
more likely to suffer complications).(14) This
increasing avoidance behavior (negative defensive medicine) is
contributing to a situation in which many smaller towns and cities
have little or no access to medical specialists. For example, more
than 48% of Massachusetts physicians surveyed in 2007 reported that
they currently alter or limit their day-to-day practice activities
because of the fear of being sued.(14)

Considering the case presented
and the data mentioned above, defensive medicine is likely quite
common, contributes substantially to rising health care costs, and
is a threat to patient safety in multiple ways. How can physicians
stem the tide of defensive medicine and practice medicine and
surgery in a patient-centered fashion based on the evidence? One
might consider Clinical Practice Guidelines (CPGs). In 1989, the
predecessor to the Agency for Healthcare Research and Quality
(AHRQ) was created within the Department of Health and Human
Services (DHHS). Among other things, its purpose was to promote the
development and certification of CPGs. Since then, the profession
has witnessed an explosion of guidelines from many different
sources. A full discussion of developing and employing practice
guidelines is beyond the scope of this commentary. Nonetheless,
implementing such guidelines within health care systems may allow
providers to follow clear pathways for diagnostic tests and
treatments.

Perhaps if the patient in
this case was treated according to an official CPG or national
standard of care (consider the American College of Radiology
Appropriateness Criteria [15] as an
example), the physicians involved would not have felt the need to
practice defensive medicine, and the patient would have obtained
only one abdominal scan as opposed to 12. One can envision an
environment in which a patient with abdominal pain but no other
findings (of an infection or other abdominal catastrophe) could be
reassured and managed with pain control, the physicians protected
from liability through their guideline-concordant practice, and the
patient protected from a clinically unnecessary CT scan. Such a
world is unlikely to be seen soon, but creating it will be a key
intervention if we are to promote safe and efficient health
care.

Take-Home
Points

  • Defensive medicine is a major driver of
    increasing health care costs.
  • 80%-90% of doctors practice defensive
    medicine.
  • Defensive medicine is a threat to
    patient safety: the patient in this case received doses of
    radiation similar to those who survived the atomic bomb.
  • The creation of national CPGs and the
    creation of a national standard of care offer a powerful strategy
    to avoid the practice of defensive medicine.

Manish K. Sethi,
MD
Harvard Combined Orthopaedic Program

Harvard Medical School

References

1. Baicker K, Fisher ES, Chandra A. Malpractice
liability costs and the practice of medicine in the Medicare
program. Health Aff (Millwood). 2007;26:841-852. [go to
PubMed]

2. Poisal PA, Truffer C, Smith S, et al. Health
spending projections through 2016: modest changes obscure part D's
impact. Health Aff (Millwood). 2007;26:w242-w253. [go to
PubMed]

3. Iglehart JK. Obama's vision and the prospects
for health care reform. N Engl J Med. 2009;361:e25. [go to
PubMed]

4. US Congress, Office of Technology Assessment.
Defensive Medicine and Medical Malpractice. Washington, DC: US
Government Printing Office; July 1994. OTA-H—602.

5. Hershey N. The defensive practice of medicine:
myth or reality. Milbank Mem Fund Q. 1972;50:69-98. [go to
PubMed]

6. Kessler D, McClellan M. Do doctors practice
defensive medicine? Quarterly J Econ May. 1996;111:353-390.
[Available at]

7. Studdert DM, Mello MM, Sage WM, et al.
Defensive medicine among high-risk specialist physicians in a
volatile malpractice environment. JAMA. 2005;293:2609-2617.
[go to
PubMed]

8. Sethi MK, Aseltine RH Jr, Ehrenfeld JM, et al;
Massachusetts Medical Society. Investigation of defensive medicine
in Massachusetts; November 2008. [Available at]

9. Reynolds RA, Rizzo JA, Gonzalez ML. The cost
of medical professional liability. JAMA. 1987;257:2776-2781.
[go to
PubMed]

10. Rubin RJ, Mendelson DN. Estimating the Costs
of Defensive Medicine. Fairfax, VA: Lewin-VHI, Inc.; January 27,
1993.

11. Berrington de González A, Mahesh M,
Kim KP, et al. Projected cancer risks from computed tomographic
scans performed in the United States in 2007. Arch Intern Med.
2009;169:2071-2077. [go to
PubMed]

12. Smith-Bindman R, Lipson J, Marcus R, et al.
Radiation dose associated with common computed tomography
examinations and the associated lifetime attributable risk of
cancer. Arch Intern Med. 2009;169:2078-2086. [go to
PubMed]

13. Localio AR, Lawthers AG, Bengtson JM, et al.
Relationship between malpractice claims and caesarean delivery.
JAMA. 1993;269:366-373. [go to PubMed]

14. 2007 MMS Physician Workforce Study. Waltham,
MA: Massachusetts Medical Society; June 2007. [Available at]

15. American College of Radiology. ACR
Appropriateness Criteria®. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx.
Accessed February 23, 2010.